Outcomes of a brief sexual health intervention for homeless youth

Cancer care and treatment during homelessness

People experiencing homelessness have not yet benefited from the substantial progress made in managing cancers, including advances in chemotherapy and radiotherapy, surgical interventions, multidisciplinary team approaches, and integrated cancer care models. People experiencing homelessness are at higher risks of developing cancers and their mortality due to cancer is twice that of the general population. Potential interventions to improve access to cancer treatment include alliances and active engagement with community organisations and shelters, cancer case management and peer-to-peer support, mHealth and navigation strategies, tailored hospital discharge to adult group homes, well equipped subacute rehabilitation centres, and specialised shelters and respite housing to assure appropriate follow-up care. Other interventions include improving preventive care, expanding data, targeted policy efforts, and broader housing advocacy. In this Personal View, I discuss challenges and opportunities in cancer treatment, with a review of the current evidence on potential interventions, and highlight strategies to improve access to cancer care for homeless populations.

Ensuring equity with pre-clinical planning for chlamydia vaccines

Chlamydia trachomatis (Ct) remains the most common bacterial sexually transmitted pathogen worldwide, causing significant morbidity particularly among women, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Several vaccines are advancing through pre-clinical and clinical development, and it is likely that one or more vaccines will progress into human efficacy trials soon. In this Perspective, we present a case for considering the challenges of Ct vaccine development through a lens of equity and justice. These challenges include the need to protect against multiple serovars, in both females and males, at multiple anatomic sites, and in resource poor areas of the world. We propose that early consideration of vaccine implementation by conducting community-engaged research will ensure that a scientifically sound chlamydia vaccine promotes equity, justice, and shared-gendered responsibility for STI prevention.

Birth Control Access and Selection among Youths Experiencing Homelessness in the United States: A Review

Youths experiencing homelessness (YEH) become pregnant at five times the general population rate. Education, social, and health care systems struggle to adequately address this young community's sexual and reproductive health needs, yet social workers are well positioned across sectors to address their sexual and reproductive health and well-being. A growing body of literature exists on the factors affecting YEH's access and selection of birth control, prompting the present review that aimed to understand this process and inform better attuned sexual and reproductive health approaches. Using a systematic search and analytic approach, we retrieved 203 articles, of which 23 met inclusion criteria. Key findings emerged across socioecological levels, including barriers and facilitators to condom use; the differential impact on YEH of hormonal birth control side effects; and the devastating effects of economic insecurity leading to sexual exploitation, survival sex, and exposure to violence. Implications include the need for multilevel intervention that addresses youths' knowledge, attitudes, and behavior as well the need to improve social norms and system design to provide better attuned care for YEH.

Sex out of marriage and condom use among homeless youth in Iran

OBJECTIVES

Sexual behaviors of homeless youth in Iran have not been well studied. This study aimed to measure the frequency and associated factors of sex out of marriage and condom use among homeless youth in Kerman, Iran.

STUDY DESIGN

In this cross-sectional study, we recruited 202 homeless youth (age: 15-29 years who experienced 30 or more days of homelessness in the last 12 months) from 11 street locations between September to December 2017.

METHODS

Of 202 participants, 169 (83.7%) reported sex in the last 12 months and were include in this analysis. We assessed the prevalence of sex out of marriage in the last 12 months, condom use in last sex, and then evaluated their covariates in multivariable logistic regression analysis.

RESULTS

The prevalence of sex out of marriage was 19.6% (95% confidence intervals [CIs]: 13.8%, 26.3%) and the prevalence of condom use was 43.8% (95% CI: 36.2%, 51.6%). Sex out of marriage was significantly correlated with male gender (adjusted odds ratio [AOR]: 24.38; 95% CI: 3.1-192.1) and being unmarried (AOR: 5.94; 95% CI: 2.3-15.5). Condom use was significantly correlated with male gender (AOR: 2.16; 95% CI: 1.1-4.2) and higher educational status (AOR: 4.30; 95% CI: 2.1-8.8).

CONCLUSION

Our findings indicate that one in five homeless youth had sex out of marriage, and less than half did no use condom. These should be addressed by adapting education and harm reduction programs targeting this specific population in Iran.

Addressing Intersecting Social and Mental Health Needs Among Transition-Age Homeless Youths: A Review of the Literature

Homelessness among youths is a poorly understood and complex social phenomenon. The authors examined the risk factors for homelessness among transition-age young adults, including the unique mental health concerns that often perpetuate the cycle of poverty and housing instability among these youths. The authors discuss the treatment gaps for mental health conditions in this population and identify potential solutions for reducing existing barriers to care. A literature review revealed that many studies report high rates of trauma and subsequent mental health problems among homeless youths. Intervention studies are challenging to conduct with this population and often have high attrition rates. Youths who are homeless desire mental health services and are especially enthusiastic about programs that address interpersonal difficulties and emotion regulation. Clinical data suggest that future interventions should address trauma more directly in this population. Technology-based interventions may help address the needs of homeless youths and may maximize their access to care. Because youths strongly prefer technology-based platforms, future research should integrate these platforms to better address the mental health needs identified as most salient by homeless youths. The authors discuss proposed policy changes at local, state, and federal levels to improve uptake of this proposed strategy.

Narrative Review: Sexually Transmitted Diseases and Homeless Youth-What Do We Know About Sexually Transmitted Disease Prevalence and Risk?

BACKGROUND

Homelessness affects an estimated 1.6 million US youth annually. Compared with housed youth, homeless youth are more likely to engage in high-risk behaviors, including inconsistent condom use, multiple sex partners, survival sex, and alcohol/drug use, putting them at increased sexually transmitted disease (STD) risk. However, there is no national estimate of STD prevalence among this population.

METHODS

We identified 10 peer-reviewed articles (9 unique studies) reporting STD prevalence among homeless US youth (2000-2015). Descriptive and qualitative analyses identified STD prevalence ranges and risk factors among youth.

RESULTS

Eight studies reported specific STD prevalence estimates, mainly chlamydia, gonorrhea, and syphilis. Overall STD prevalence among homeless youth ranged from 6% to 32%. STD rates for girls varied from 16.7% to 46%, and from 9% to 13.1% in boys. Most studies were conducted in the Western United States, with no studies from the Southeast or Northeast. Youths who experienced longer periods of homelessness were more likely to engage in high-risk sexual behaviors. Girls had lower rates of condom use and higher rates of STDs; boys were more likely to engage in anal and anonymous sex. Additionally, peer social networks contributed to protective effects on individual sexual risk behavior.

CONCLUSIONS

Sexually transmitted disease prevalence estimates among homeless youth fluctuated greatly by study. Sexually transmitted disease risk behaviors are associated with unmet survival needs, length of homelessness, and influence of social networks. To promote sexual health and reduce STD rates, we need better estimates of STD prevalence, more geographic diversity of studies, and interventions addressing the behavioral associations identified in our review.

Trauma-Focused Cognitive Behavioral Therapy for Commercially Sexually Exploited Youth

Commercially sexually exploited children and adolescents ("commercially exploited youth")present numerous clinical challenges that have led some mental health providers to question whether current evidence-based treatments are adequate to address the needs of this population. This paper 1) addresses commonalities between the trauma experiences, responses and treatment challenges of commercially exploited youth and those of youth with complex trauma; 2) highlights the importance of careful assessment to guide case conceptualization and treatment planning for commercially exploited youth; and 3) describes strategies for implementing Trauma-Focused Cognitive Behavioral Therapy for complex trauma specific to these youth.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Millions of street-connected children and young people worldwide live or work in street environments. They are vulnerable to many risks, whether or not they remain connected to families of origin, and despite many strengths and resiliencies, they are excluded from mainstream social structures and opportunities.

OBJECTIVES

Primary research objectivesTo evaluate and summarise the effectiveness of interventions for street-connected children and young people that aim to:• promote inclusion and reintegration;• increase literacy and numeracy;• facilitate access to education and employment;• promote mental health, including self esteem;• reduce harms associated with early sexual activity and substance misuse. Secondary research objectives• To explore whether effects of interventions differ within and between populations, and whether an equity gradient influences these effects, by extrapolating from all findings relevance for low- and middle-income countries (LMICs) (Peters 2004).• To describe other health, educational, psychosocial and behavioural effects, when appropriate outcomes are reported.• To explore the influence of context in design, delivery and outcomes of interventions.• To explore the relationship between numbers of components and duration and effects of interventions.• To highlight implications of these findings for further research and research methods to improve evidence in relation to the primary research objective.• To consider adverse or unintended outcomes.

SEARCH METHODS

We searched the following bibliographic databases, searched for the original review, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and Pre-MEDLINE; EMBASE and EMBASE Classic; Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycINFO; Education Resource Information Center (ERIC); Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; Latin American Caribbean Health Sciences Literature (LILACS); System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and International Monetary Fund (IMF) Libraries; British Library for Development Studies (BLDS); Google and Google Scholar. We updated the search in April 2015 for the review update, using the same methods.

SELECTION CRITERIA

This review includes data from harm reduction or reintegration intervention studies that used a comparison group study design; all were randomised or quasi-randomised studies. Studies were included if they evaluated interventions provided for street-connected children and young people, from birth to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and other factors presented in the Discussion and Summary quality assessment (Grades of Recommendation, Assessment, Development and Evaluation (GRADE)). We extracted data on intervention delivery, context, process factors, equity and outcomes, and grouped outcomes into psychosocial outcomes, risky sexual behaviours or substance use. We conducted meta-analyses for outcomes where the outcome measures were sufficiently similar. We evaluated other outcomes narratively.

MAIN RESULTS

We included 13 studies evaluating 19 interventions from high-income countries (HICs). We found no sufficiently robust evaluations conducted in low- and middle-income countries (LMICs). Study quality overall was low and measurements used by studies variable. Participants were classified as drop-in and shelter-based. No studies measured the primary outcome of reintegration and none reported on adverse effects.We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexually risky behaviours . Interventions evaluated consisted of time-limited therapeutically based programmes that proved no more effective than standard shelter or drop-in services and other control interventions used for most outcomes in most studies. Favourable changes from baseline were reported for outcomes for most participants following therapy interventions and standard services. We noted considerable heterogeneity between studies and inconsistent reporting of equity data. No studies measured the primary outcome of reintegration or reported on adverse effects.

AUTHORS' CONCLUSIONS

Analysis revealed no consistently significant benefit for focused therapeutic interventions compared with standard services such as drop-in centres, case management and other comparable interventions for street-connected children and young people. Commonly available services, however, were not rigorously evaluated. Robust evaluation of interventions, including comparison with no intervention, would establish a more reliable evidence base to inform service implementation. More robust research is needed in LMICs to examine interventions for street-connected children and young people with different backgrounds and service needs.

A systematic review of sexual health interventions for adults: narrative evidence

Recent work has explored the intersection between sexual health (as construed by the World Health Organization and others) and public health domains of action in the United States of America. This article reports the narrative results of a systematic review of sexual health intervention effects on public health-relevant outcomes. To qualify, interventions had to be based on the principles (1) that sexual health is intrinsic to individuals and their overall health and (2) that relationships reflecting sexual health must be positive for all parties concerned. Outcomes were classed in domains: knowledge, attitudes, communication, health care use, sexual behavior, and adverse events. We summarized data from 58 studies (English language, adult populations, 1996-2011) by population (adults, parents, sexual minorities, vulnerable populations) across domains. Interventions were predominantly individual and small-group designs that addressed sexual behaviors (72%) and attitudes/norms (55%). They yielded positive effects in that 98% reported a positive finding in at least one domain; 50% also reported null effects. The most consistently positive effects on behaviors and adverse events were found for sexual minorities, vulnerable populations, and parental communication. Whether via direct action or through partnerships, incorporating principles from existing sexual health definitions in public health efforts may help improve sexual health.

Sexual health interventions: a meta-analysis

In the second of two companion papers, we conducted a meta-analysis of sexual health interventions in three domains. The interventions chosen for the meta-analysis were a subset of studies presented in a narrative review (the first of the two companion papers); these in turn were selected on the basis of fit to principles derived from the World Health Organization (WHO) and other definitions of sexual health. Studies (n=20) were drawn from Medline and PsycINFO databases (English language, adult populations, 1996-2011) and fell into three domains: knowledge, attitudes, and sexual behaviors. We estimated intervention effects via Hedges' g, using the random-effects approach. Initial estimates revealed a large effect for knowledge, g=1.32 (95% CI=0.51-2.14), and smaller effects for attitude change, g=0.17 (0.11-0.24) and behavior, g=0.21 (0.13-0.29). After removing outliers to produce more precise estimates, the final effect sizes for knowledge, attitudes, and sexual behavior were, respectively, 0.25 (0.03-0.48), 0.18 (0.12-0.24), and 0.18 (0.11-0.24). Interventions yielded positive effects across populations and in all the domains studied.

The impact of psychosocial factors on subjective well-being among homeless young adults

Homeless young adults are one of this country's most vulnerable populations, and information surrounding issues of subjective well-being among this particularly diverse population is scarce. The purpose of this study was to examine the impact social support, future expectations, and homeless cultural factors have on subjective well-being among homeless young adults. A purposive sample of 185 homeless young people, ages 18 to 23, and known to use alcohol or drugs, participated in the study. Multiple regression analyses showed that participants who had a higher level of subjective well-being reported significantly higher levels of social support, more optimistic expectations of the future, and a better perception of the flow of time. More fatalistic views of the future significantly predicted lower levels of subjective well-being. Findings suggest that service providers should focus on understanding the strengths of individuals and, specifically, gain a deeper understanding of homeless young adults' support networks and views of the future.

Reducing High Risk Behaviors among Street Living Youth: Outcomes of an Integrated Prevention Intervention

Research efforts to reduce Human Immunodeficiency Virus (HIV) risk behavior among street living youth have shown disappointing outcomes, with few studies reporting reduced risk behaviors. The current study tested the impact of an integrated HIV prevention intervention, and predictors of change, for youth (N=270) between the ages of 14 to 20 years receiving substance use treatment through a drop-in center. Condom use, HIV knowledge, number of sexual partners and behaviors associated with an overall HIV risk index were assessed at baseline, 3, 6 and 12 months post-baseline. Findings suggest that HIV prevention integrated with substance use treatment is associated with increased condom use and reduced sex partners. However, the effects on condom use were short lived and dissipated by 12 months post-baseline. Higher treatment attendance and baseline substance use predicted increased condom use. Although no significant change was observed in the overall HIV risk index, increases in depressive symptoms were associated with increases in the index score, as well as more sexual partners. Future research should determine whether successful intervention requires reinforcement of risk reduction behaviors while youth remain homeless.

Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections

OBJECTIVE

To explore how gender is addressed in medical articles on the prevention of sexually transmissible infections (STI) among adolescents.

METHODS

Sixtyone articles were retrieved from a PubMed search and scrutinized by qualitative content analysis.

RESULTS

Most articles were affiliated with North American research institutions, but there were also reports from Europe, Africa, South America, and Asia. Gender turned up in the following four recurrent discourses: Gendered Receptiveness for Information, Stereotyped Heterosexual Expectations, Power Imbalance in Sexual Relations, and Gendered Prevention Approaches. Young women were described as knowledgeable, communicative, and responsible, but at risk because of feminine ideals and a lack of negotiating power. Men were described as less informed, more reluctant to discuss, and more risk taking due to masculine ideals and power dominance. Prevention approaches concerned how to postpone sex and/or tailor gender-sensitive programs for specific groups of young women and men.

CONCLUSION

Researchers' own gender expectations might have a substantial impact on how sex and sexual health is considered in prevention research. To avoid reconstruction of current inequalities and stereotypes regarding sexual practices of young women and men, the impact of gender, the power structures in intimate relations, and the cultural context should be considered. Medical research on STI prevention could benefit from including a wider array of gender perspectives.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Numbers of street-connected children and young people run into many millions worldwide and include children and young people who live or work in street environments. Whether or not they remain connected to their families of origin, and despite many strengths and resiliencies, they are vulnerable to a range of risks and are excluded from mainstream social structures and opportunities.

OBJECTIVES

To summarise the effectiveness of interventions for street-connected children and young people that promote inclusion and reintegration and reduce harms. To explore the processes of successful intervention and models of change in this area, and to understand how intervention effectiveness may vary in different contexts.

SEARCH METHODS

We searched the following bibliographic databases, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and PreMEDLINE; EMBASE and EMBASE Classic; CINAHL; PsycINFO; ERIC; Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; LILACS; System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and IMF Libraries; BLDS (British Library for Development Studies); Google, Google Scholar.

SELECTION CRITERIA

The review included data from harm reduction or reintegration promotion intervention studies that used a comparison group study design and were all randomised or quasi-randomised studies. Studies were included if they evaluated interventions aimed to benefit street-connected children and young people, aged 0 to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Data were extracted on intervention delivery, context, process factors, equity and outcomes. Outcome measures were grouped according to whether they measured psychosocial outcomes, risky sexual behaviours or substance use. A meta-analysis was conducted for some outcomes though it was not possible for all due to differences in measurements between studies. Other outcomes were evaluated narratively.

MAIN RESULTS

We included 11 studies evaluating 12 interventions from high income countries. We did not find any sufficiently robust evaluations conducted in low and middle income countries (LMICs) despite the existence of many relevant programmes. Study quality overall was low to moderate and there was great variation in the measurement used by studies, making comparison difficult. Participants were drop-in and shelter based. We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexual risky behaviours despite the many measurements collected in the studies. The interventions being evaluated consisted of time limited therapeutically based programmes which did not prove more effective than standard shelter or drop-in services for most outcomes and in most studies. There were favourable changes from baseline in outcomes for most particpants in therapy interventions and also in standard services. There was considerable heterogeneity between studies and equity data were inconsistently reported. No study measured the primary outcome of reintegration or reported on adverse effects. The review discussion section included consideration of the relevance of the findings for LMIC settings.

AUTHORS' CONCLUSIONS

Analysis across the included studies found no consistently significant benefit for the 'new' interventions compared to standard services for street-connected children and young people. These latter interventions, however, have not been rigorously evaluated, especially in the context of LMICs. Robustly evaluating the interventions would enable better recommendations to be made for service delivery. There is a need for future research in LMICs that includes children who are on the streets due to urbanisation, war or migration and who may be vulnerable to risks such as trafficking.

The primary health care service experiences and needs of homeless youth: a narrative synthesis of current evidence

Homeless youth are a growing, vulnerable population with specific primary health care (PHC) requirements. There are no systematic reviews of evidence to guide the delivery of PHC interventions to best address the needs of homeless youth in Australia. We present a narrative synthesis of peer reviewed research designed to determine: (1) the PHC services homeless youth access; (2) experiences of services, reported outcomes and barriers to use; and, (3) the PHC service needs of homeless youth. Findings show that homeless youth access a variety of services and delivery approaches. Increased PHC use is associated with youth who recognise they need help. Street-based clinic linked services and therapy and case management alongside improved housing can positively impact upon mental health and substance use outcomes. Barriers to service use include knowledge; provider attitudes, financial constraints and inappropriate environments. Findings support targetted, co-ordinated networks of PHC and housing services with nurses working alongside community workers.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Numbers of street-connected children and young people run into many millions worldwide and include children and young people who live or work in street environments. Whether or not they remain connected to their families of origin, and despite many strengths and resiliencies, they are vulnerable to a range of risks and are excluded from mainstream social structures and opportunities.

OBJECTIVES

To summarise the effectiveness of interventions for street-connected children and young people that promote inclusion and reintegration and reduce harms. To explore the processes of successful intervention and models of change in this area, and to understand how intervention effectiveness may vary in different contexts..

SEARCH METHODS

We searched the following bibliographic databases, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and PreMEDLINE; EMBASE and EMBASE Classic; CINAHL; PsycINFO; ERIC; Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; LILACS; System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and IMF Libraries; BLDS (British Library for Development Studies); Google, Google Scholar.

SELECTION CRITERIA

The review included data from harm reduction or reintegration promotion intervention studies that used a comparison group study design and were all randomised or quasi-randomised studies. Studies were included if they evaluated interventions aimed to benefit street-connected children and young people, aged 0 to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Data were extracted on intervention delivery, context, process factors, equity and outcomes. Outcome measures were grouped according to whether they measured psychosocial outcomes, risky sexual behaviours or substance use. A meta-analysis was conducted for some outcomes though it was not possible for all due to differences in measurements between studies. Other outcomes were evaluated narratively.

MAIN RESULTS

We included 11 studies evaluating 12 interventions from high income countries. We did not find any sufficiently robust evaluations conducted in low and middle income countries (LMICs) despite the existence of many relevant programmes. Study quality overall was low to moderate and there was great variation in the measurement used by studies, making comparison difficult. Participants were drop-in and shelter based. We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexual risky behaviours despite the many measurements collected in the studies. The interventions being evaluated consisted of time limited therapeutically based programmes which did not prove more effective than standard shelter or drop-in services for most outcomes and in most studies. There were favourable changes from baseline in outcomes for most particpants in therapy interventions and also in standard services. There was considerable heterogeneity between studies and equity data were inconsistently reported. No study measured the primary outcome of reintegration or reported on adverse effects. The review discussion section included consideration of the relevance of the findings for LMIC settings.

AUTHORS' CONCLUSIONS

Analysis across the included studies found no consistently significant benefit for the 'new' interventions compared to standard services for street-connected children and young people. These latter interventions, however, have not been rigorously evaluated, especially in the context of LMICs. Robustly evaluating the interventions would enable better recommendations to be made for service delivery. There is a need for future research in LMICs that includes children who are on the streets due to urbanisation, war or migration and who may be vulnerable to risks such as trafficking.

Impact of nursing intervention on decreasing substances among homeless youth

BACKGROUND

Alcohol use, and in particular, binge drinking, and methamphetamine use is pervasive among homeless youth and remains a social pressure among this vulnerable population. However, there is no compelling evidence that specific interventions for reducing drug and alcohol use are effective for homeless youth.

OBJECTIVES

This community-based participatory action pilot study assessed the impact of an intervention study focused on decreasing use of drugs and alcohol among a sample of homeless young adults (N= 154) visiting a drop-in site in Santa Monica, California. The two programs consisted of an HIV/AIDS and Hepatitis Health Promotion (HHP) program led by nurses and an Art Messaging (AM) program led by artists. Six-month follow-up data were obtained from 100 of these individuals.

RESULTS

Findings revealed significant reductions in alcohol and marijuana use and binge drinking in both the HHP and AM programs. However, homeless youth in the HHP program reported additional reductions in methamphetamine, cocaine, and hallucinogen use at 6-month follow-up.

CONCLUSIONS

Reductions in drugs and alcohol are important as these substances are linked to HIV/AIDS, hepatitis, and other health risks in homeless youth.

SCIENTIFIC SIGNIFICANCE

The successful outcomes of the study intervention validate the utility of nurse-led and artistic health promotion strategies to decrease drug and alcohol use and other risky behaviors in homeless youth populations.

Investigating community-based health and health promotion for homeless people: a mixed methods review

Homeless people are susceptible to a range of health problems, yet in terms of health promotion, tend to be a hard-to-reach, marginalized group. Robust evidence regarding the ability to engage with this population via effective health promotion programmes is essential if policy and practice are to be informed to improve the health of homeless people. A structured review was conducted with the aim of examining what is known about community-based health promotion for homeless people. Six databases were searched and 8435 records screened. Thirteen studies met the inclusion criteria. A mixed-methods 'combined separate synthesis' approach was used to accommodate both quantitative and qualitative evidence within one review. Three themes emerged: (i) incorporating homelessness, (ii) health improving and (iii) health engaging. The review has implications for health promotion design, with evidence suggesting that as part of a tailored approach, homeless people must be actively involved in intervention development, ensuring that appropriate, acceptable and potentially effective individual elements are incorporated into community-based interventions.

Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review

BACKGROUND

Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status.

METHODS

A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality.

RESULTS

Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations.

CONCLUSIONS

These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.

Multi-city assessment of lifetime pregnancy involvement among street youth, Ukraine

Although street youth are at increased risk of lifetime pregnancy involvement (LPI), or ever becoming or getting someone pregnant, no reports to date describe the epidemiology of LPI among systematically sampled street youth from multiple cities outside of North America. The purpose of our assessment was to describe the prevalence of and risk factors associated with LPI among street youth from three Ukrainian cities. We used modified time-location sampling to conduct a cross-sectional assessment in Odesa, Kyiv, and Donetsk that included citywide mapping of 91 public venue locations frequented by street youth, random selection of 74 sites, and interviewing all eligible and consenting street youth aged 15-24 years found at sampled sites (n = 929). Characteristics of youth and prevalence of LPI overall and by demographic, social, sexual, and substance use risk factors, were estimated separately for males and females. Adjusted odds ratios (AORs) were calculated with multivariable logistic regression and effect modification by gender was examined. Most (96.6%) eligible youth consented to participate. LPI was reported for 41.7% of females (93/223) and 23.5% of males (166/706). For females, LPI was significantly elevated and highest (>70%) among those initiating sexual activity at ≤12 years and for those reporting lifetime anal sex and exchanging sex for goods. For males, LPI was significantly elevated and highest (>40%) among those who reported lifetime anal sex and history of a sexually transmitted infection. Overall, risk factors associated with LPI were similar for females and males. Among the total sample (females and males combined), significant independent risk factors with AORs ≥2.5 included female gender, being aged 20-24 years, having five to six total adverse childhood experiences, initiating sex at age ≤12 or 13-14 years, lifetime anal sex, most recent sex act unprotected, and lifetime exchange of sex for goods. Among street youth with LPI (n = 259), the most recent LPI event was reported to be unintended by 63.3% and to have ended in abortion by 43.2%. In conclusion, our assessment documented high rates of LPI among Ukrainian street youth who, given the potential for negative outcomes and the challenges of raising a child on the streets, are in need of community-based pregnancy prevention programs and services. Promising preventive strategies are discussed, which are likely applicable to other urban populations of street-based youth as well.

Protective factors associated with fewer multiple problem behaviors among homeless/runaway youth

Although homeless youth exhibit numerous problem behaviors, protective factors that can be targeted and modified by prevention programs to decrease the likelihood of involvement in risky behaviors are less apparent. The current study tested a model of protective factors for multiple problem behavior in a sample of 474 homeless youth (42% girls; 83% minority) ages 12 to 24 years. Higher levels of problem solving and planning skills were strongly related to lower levels of multiple problem behaviors in homeless youth, suggesting both the positive impact of preexisting personal assets of these youth and important programmatic targets for further building their resilience and decreasing problem behaviors. Indirect relationships between the background factors of self-esteem and social support and multiple problem behaviors were significantly mediated through protective skills. The model suggests that helping youth enhance their skills in goal setting, decision making, and self-reliant coping could lessen a variety of problem behaviors commonly found among homeless youth.

Better to bend than to break: coping strategies utilized by substance-abusing homeless youth

This study investigated the relationship between coping styles and problem behaviors among a sample of substance-abusing homeless youth. Homeless youth (n = 268) were recruited through the only drop-in center in Albuquerque, New Mexico. Results revealed that youth with higher task-oriented coping reported less delinquent behaviors while those with higher emotion-oriented coping reported higher levels of anxiety/ depression and higher delinquency. Contrary to expectations, youth utilizing higher avoidance-oriented coping skills showed fewer HIV risk behaviors, fewer anxiety/depressive symptoms, and less frequent alcohol use. Findings emphasize the need to examine coping strategies in the context that individuals are situated.

Social Estrangement: Factors Associated with Alcohol or Drug Dependency among Homeless, Street-Involved Young Adults

Substance use is highly prevalent among homeless, street-involved young people. Societal estrangement is often associated with substance use, particularly among this population. The current study utilized a descriptive correlational design to identify four domains of social estrangement: disaffiliation, human capital, identification with homeless culture, and psychological dysfunction. These domains were tested to determine their association with alcohol or drug dependence. Interviews utilizing self-report instruments were conducted with 185 young adults aged 18–23 years of age who were receiving homeless services from a community drop-in center. In this sample, the vast majority reported high levels of alcohol and drug use with more than half being identified as dependent on alcohol and/or drugs. Polysubstance use was highly prevalent and most reported marijuana as their drug of choice. Findings indicate that identification with homeless culture was the most highly predictive domain of social estrangement for both alcohol and drug dependency. Implications for services to this population are discussed.

A Review of Services and Interventions for Runaway and Homeless Youth: Moving Forward

Research focused on the impact of community-based services and treatment interventions designed to intervene in the lives of runaway and homeless youth has increased in the last two decades in the U.S. and internationally. In light of the tremendous need for identifying effective strategies to end homelessness and its associated problems among youth, this paper summarizes and critiques the findings of the extant literature including U.S., international, and qualitative studies. Thirty-two papers met criteria for inclusion in the review. Among the conclusions are that comprehensive interventions which target the varied and interconnected needs of these youth and families may be worthy of more study than studies that isolate the intervention focus on one problem. Also, more research incorporating design strategies that increase the reliability and validity of study findings is needed. Other preliminary conclusions and future directions are offered.

Ageing and sexual health in the UK: how should health psychology respond to the challenges?

The UK has an increasing ageing population and, like other western societies, has undergone several significant shifts over the last 50 years, including attitudes towards sexual activity, relationships and growing older. Drawing on evidence from a range of sources and a number of disciplines, this editorial examines the potential sexual and reproductive health implications for current and future cohorts of ;older' people, and considers the role of health psychology in responding to the challenges of growing older in a rapidly changing (sexualized, digitalized and medicalized) world.

Health educators' perceptions of a sexual health intervention for homeless adolescents

OBJECTIVE

The purpose of this qualitative descriptive study was to explore the perceptions and experiences of health educators in providing a brief, street-based intervention to homeless adolescents.

METHOD

Qualitative data were collected via e-mail from a purposive sample of 13 male and female health educators who provided the intervention and analyzed using manifest and latent content analysis techniques.

RESULTS

Five categories with two or more subcategories were identified in the data and included how the educators' views changed, how they felt homeless youth were similar to and different from other adolescents, positive aspects and challenges of providing the intervention, and suggestions for future interventionists working with this population.

CONCLUSIONS

The health educators' practice was strengthened over the course of providing the intervention through their positive experiences, changes in their perceptions, some of which were biased, and ability to confront the challenges that accompany working with this vulnerable population.

PRACTICE IMPLICATIONS

Health educators who work with this population should learn about the culture of homeless youth and characteristics of homeless youth that may influence their participation in a sexual health intervention. Moreover, they need to be non-judgmental, practice the intervention, be aware of their biases, and remain flexible.